Research Article

Assessment of cardiovascular changes among chronic obstructive

pulmonary disease patients at rural tertiary care center of Northern India

Adesh Kumar, Ashish Kumar Gupta, Aditya Kumar Gautam, Bal Krishna Kushwaha, Prashant Yadav,
Vijay Kumar Verma

Department of Respiratory Medicine, U. P. University of Medical Sciences, Saifai, Etawah, Uttar Pradesh, India
Correspondence to: Prashant Yadav, E-mail: dr.prashantyadav10@gmail.com

Received: May 23, 2017; Accepted: June 14, 2017

ABSTRACT

Background: Chronic obstructive pulmonary disease (COPD) is a complex systemic disease that has significant
extrapulmonary effects along with pulmonary involvement. Cardiovascular manifestation is one of the most common
comorbidities of COPD. Patients with COPD also carry an increased risk of mortality due to cardiovascular abnormalities
compared with those who do not have these comorbidities. As the cardiac abnormalities clearly contribute to the overall
mortality and morbidity associated with COPD, an understanding of their role and potential for treatment is vital; therefore,
this study was done. Objectives: This study aimed to study the assessment of cardiovascular manifestation in COPD.
Materials and Methods: This was a cross-sectional study done in the Respiratory Medicine Department of rural tertiary
care center during the period from January 2015 to June 2016. A total of 200 study subjects fulfilling the inclusion criteria
and consenting to participate were included in the study. The diagnosis of COPD is based on the clinical history, clinical
examination, X-ray chest, and spirometry. All patients were further subjected to electrocardiogram (ECG) and two-
dimensional echocardiography (2D-ECHO) for cardiac evaluation. Results: On ECG evaluation: Arrhythmia was found in
99 (49.5%) cases, right ventricular (RV) hypertrophy (RVH) in 61 (30.5%) cases, right atrial enlargement (RAE) in 52 (26%)
cases, right bundle branch block in 20 (10%) cases, poor progression of R wave in 24 (12%) cases, and right axis deviation
was found in 30 (15%) cases. On 2D-ECHO evaluation: tricuspid regurgitation was found in a 117 (58.5%) cases, pulmonary
hypertension in 116 (58%) cases, RAE in 79 (39.5%) cases, RVH in 74 (37%) cases, RV enlargement in 55 (27.5%) cases,
and left ventricular diastolic dysfunction in 113 (56.05%) cases. Conclusion: The study shows that cardiac disorders are
highly prevalent in patients with severe-to-very severe COPD. ECHO is a simple non-invasive tool for evaluation of cardiac
functions in patients with COPD during acute exacerbation as well as during the follow-up of the disease.

KEY WORDS: Chronic Obstructive Pulmonary Disease; Corpulmonale; Echocardiography; Electrocardiogram

INTRODUCTION persistent airflow limitation that is usually progressive and

Chronic obstructive pulmonary disease (COPD) is a common
preventable and treatable disease which is characterized by
Access this article online
Website: http://www.ijmsph.com
DOI: 10.5455/ijmsph.2017.0513914062017
associated with an enhanced chronic inflammatory response
in the airways and the lung to noxious particles or gases. The
exacerbations and comorbidities contribute to the overall
severity in individual patients.[1] COPD can no longer be
defined as a disease restricted to the lungs. COPD is the fourth-
Quick Response code leading cause of chronic morbidity and mortality worldwide,
and mortality from COPD is expected to increase further and
to rank at the third position in 2020, after coronary artery
disease and stroke.[2] COPD has significant extrapulmonary
effects along with pulmonary involvement.[3] Mortality of
COPD is increased by its comorbidities and exacerbations.[4,5]

International Journal of Medical Science and Public Health Online 2017. © 2017 Prashant Yadav, et al. This is an Open Access article distributed under the terms of the Creative Commons
Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix,
transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.

2017 | Vol 6 | Issue 8 International Journal of Medical Science and Public Health  1320
Kumar et al.
The clinical severity is increasingly being recognized as being
determined by concomitant comorbidities.[6] Pulmonary
manifestations of COPD might be one aspect of expression
of a systemic inflammation with several other organic
manifestations.[7]
Cardiovascular comorbidities among COPD patients have
been recognized for many decades. Pulmonary vascular
disease associated with COPD increases morbidity and
worsens survival. Patients with COPD also carry an
increased risk of mortality due to arrhythmia, myocardial
infarction, or congestive heart failure compared with those
who do not have these comorbidities.[8] The lung health
study showed that a substantial proportion of deaths in
patients with mild COPD was the result of cardiovascular
complications, and a recent large epidemiologic study
revealed increased cardiovascular mortality, particularly in
patients younger than 65 years with COPD.[9] As the cardiac
abnormalities clearly contribute to the overall mortality and
morbidity associated with COPD, an understanding of their
role and potential for treatment is vital, and therefore, this
study was done.
The cardiac manifestations of COPD are numerous.
Impairments of right ventricular (RV) dysfunction and
pulmonary vascular disease are well known to complicate
the clinical course of COPD and correlate inversely with
survival. The pathogenesis of pulmonary vascular disease
in COPD is likely multifactorial and related to alterations
in gas exchange and vascular biology, as well as structural
changes of the pulmonary vasculature and mechanical
factors. Several modalities currently exist for the assessment
of pulmonary vascular disease in COPD, but right heart
catheterization remains the gold standard. Although no
specific therapy other than oxygen has been generally
accepted for the treatment of pulmonary hypertension in
this population, there has been renewed interest in specific
pulmonary vasodilators. The coexistence of COPD and
coronary artery disease occurs frequently. This association
is likely related to shared risk factors as well as similar
pathogenic mechanisms, such as systemic inflammation.
Management strategies for the care of patients with COPD
and coronary artery disease are similar to those without
COPD, but care must be given to address their respiratory
limitations. Arrhythmias occur frequently in patients with
COPD but are rarely fatal and can generally be treated
medically. The use of β-blockers in the management of
cardiac disease, while a theoretical concern in patients with
increased airway resistance, is generally safe with the use of
cardioselective agents.
Aims and Objectives
1. Assessment of cardiovascular manifestation in COPD
2. To find out the correlation between cardiovascular
manifestation and severity of COPD.
1321        International Journal of Medical Science and Public Health
Assessment of cardiovascular changes among COPD
MATERIALS AND METHODS
This was a cross-sectional study done in the Respiratory
Medicine Department of tertiary care center, during the period
from January 2015 to June 2016. A total of 200 patients of
COPD of either sex having age more than 40 years were
included in the study. Patients having a history of asthma
and having a previous history of cardiovascular disease
and those who were critically ill and uncooperative were
excluded from the study. Patients who did not give consent
also excluded from the study. The diagnosis of COPD was
made on the basis of the clinical history, examination, X-ray
chest, and spirometry (ratio of post-bronchodilator forced
expiratory volume in 1st and forced vital capacity [FEV1/
FVC <70%]), further staging of COPD done on the basis of
post-bronchodilator FEV1 into four categories:
• GOLD 1: Mild FEV1 >80% predicted,
• GOLD 2: Moderate FEV1 >50% to <80% predicted,
• GOLD 3: Severe FEV1 > 30% to <50% predicted,
• GOLD 4: Very severe FEV1 <30% predicted.
Electrocardiogram (ECG) and two-dimensional
echocardiography (2D-ECHO) done for cardiac evaluation.
Routine investigation such as complete blood count, liver
function test, kidney function test, lipid profile, and random
blood sugar was done in all patients.
ECG Evaluation
A 12-lead ECG was taken in all the patients under the study,
and the following points were noted.
1. P wave changes - P pulmonale – Tall-peaked P wave
>2.5 mm in amplitude
2. Criteria for RV hypertrophy (RVH):
• Right axis deviation (>110°)
• R/S ratio in V1 >1
• R wave in V1 ≥7 mm
• S wave in V1 ≤2 mm - qR pattern in V1
• R in V1 + S in V5/V6 ≥10.5 mm
• R/S ratio in V5 or V6 <1
• RSR in V1 with R ≥10 mm.
The presence of any one of the above criteria is suggestive,
but presence of 2 or more criteria is diagnostic of RVH.[10]
3. Poor progression of R waves
4. Incomplete RBBB (rSr/rSR’ in V1) QRS ≤0.12 s.
ECHO
All patients were subjected to ECHO examination including
2D and M-mode ECHO (Esaote MyLab Class C machine)
to note the presence of pulmonary hypertension, RVH, RV
dilatation, and left ventricular diastolic dysfunction (LVDD).
The following points were noted:
1. Pulmonary artery diameter
2. Evidence of pulmonary hypertension on M-mode
examination of pulmonary valve
2017 | Vol 6 | Issue 8
Kumar et al. Assessment of cardiovascular changes among COPD

• a wave (normal - 2.7 mm) (low in pulmonary and poor progression of R wave in 24 (12%) cases (P = 0.046,
hypertension) r = 0.141). These all have a significant correlation with
• Ejection fraction (EF) slope (normal - 36.9 ± 25.4 COPD.
mm/s) (low in pulmonary hypertension)
• Mid-systolic notch and flutter. Right axis deviation was found in 30 (15%) cases (P = 0.073,
3. RVH  - Thickness of anterior wall and septum if r = 0.127), which had no significant correlation with COPD
>6 mm - RVH is present (Table 1).
4. RV diastolic dimension if >25 mm, RV is dilated
5. Right atrial dilatation (RAD) (>3.6 cm) On 2D-ECHO Evaluation
6. RV failure:
Tricuspid regurgitation in a 117 (58.5%) cases (P = 0.00,
• Tricuspid regurgitation
correlation coefficient (r) = 0.447), pulmonary hypertension
• Dilatation of inferior vena cava and hepatic veins.
in 116 (58%) cases (P = 0.00, r = 0.437), LVDD in
113 (56.05%) cases (P = 0.00, r = 0.491), RAE was found in
The presence of RV dilation, RVH, or RV failure is taken as
79 (39.5%) cases (P = 0.003, r = 0.208), RVH in 74 (37%)
evidence of corpulmonale.[10]
cases (P = 0.00, r = 0.271), and RV enlargement in 55 (27.5%)
cases (P = 0.00, r = 0.334) (Table 2).
LV function was also assessed using the following parameters:
EF = Measure of how much end-diastolic value is ejected
These all findings have a significant correlation with the
from LV with each contraction (56-78%).
severity of COPD (Tables 3 and 4).
E/A = Diastolic filling of left ventricles usually classified
initially on the basis of the peak mitral flow velocity of the DISCUSSION
early rapid filling wave (E) and peak velocity of the late filling
wave caused by atrial contraction (A). In normal subjects, There are various cardiac manifestations in COPD which
LV elastic recoil is vigorous because of normal myocardial complicate its clinical course. In patients with COPD
relaxation, therefore more filling is completed during early with associated cardiovascular diseases, the morbidity
diastolic, so LV diastolic dysfunction (LVDD) is said to be
present when E/A is <1.3 (age group 45-49 years), <1.2 (age Table 1: ECG findings in COPD patients
group 50-59 years), <1.0 (age group 60-69 years), and <0.8 ECG parameter Number of patients (%)
(age group ≥70 years).[11] Right axis deviation 52 (26)
RVH 61 (30.5)
Arrhythmia 99 (49.5)
RESULTS
Sinus tachycardia 90 (45)
The data of all 200 COPD patients were analyzed by Statistical Atrial ectopic 02 (1)
Package for Social Science software (Window version 23), Atrial tachycardia 04 (2)
and Chi-square and Z-test were used to analyze the collected Ventricular ectopics 03 (1.5)
data. It was observed that prevalence of COPD was higher Right bundle branch block 20 (10)
in 147 (73.5%) male patients as compared to 53 (26.5%) Poor progression of r wave 24 (12)
female patients in the present study. The mean age of patients Right axis deviation 30 (15)
included in the study was 58.34 ± 8.18 years. Smoking was
ECG: Electrocardiographic, COPD: Chronic obstructive pulmonary
more common in male patients (75.51%) as compared to disease, RVH: Right ventricular hypertrophy
female (18.86%), whereas biomass fuel exposure was more
common in female patients (92.45%) as compared to male Table 2: ECHO findings in COPD
(7.48%). Systemic hypertension was found in 60 (30%) cases ECHO parameter N (%)
(P = 0.150) which do not show any significant correlation
Right axis deviation 79 (39.5)
with severity of COPD.
RV enlargement 55 (27.5)
RVH 74 (37)
On ECG Evaluation TR 117 (58.5)
Arrhythmia in 99 (49.5%) cases (P = 0.00 and correlation Pulmonary hypertension 116 (58)
coefficient (r) = 0.488) and sinus tachycardia were the Corpulmonale 112 (56)
most common among arrhythmia. RVH in 61 (30.5%) LVDD 113 (56.05)
cases (P = 0.005, r = 0.197), right atrial enlargement (RAE) TR: Tricuspid regurgitation, LVDD: Left ventricular diastolic
was found in 52 (26%) patients (P = 0.006, r = 0.195), right dysfunction, ECHO: Echocardiography, RV: Right ventricular,
bundle branch block in 20 (10%) cases (P = 0.01, r = 0.182), COPD: Chronic obstructive pulmonary disease

2017 | Vol 6 | Issue 8 International Journal of Medical Science and Public Health  1322
Kumar et al.
Table 3: Correlation of corpulmonale with severity of
COPD
GOLD stage of COPD N (%)
I 2 (8.69)
II 14 (37.83)
III 29 (49.15)
IV 67 (82.71)
P=0.00, correlation coefficient (r)=0.412. COPD: Chronic
obstructive pulmonary disease
Table 4: Correlation of pulmonary hypertension with
severity of COPD
GOLD stage of COPD N (%)
I 3 (13.04)
II 17 (45.94)
III 34 (57.62)
IV 68 (83.95)
P=0.00, correlation coefficient (r)=0.437. COPD: Chronic
obstructive pulmonary disease
and mortality are seen to be increased as shown in various
studies.[12] COPD and cardiovascular diseases have various
common risk factors, including smoking and aging. The
presence of pro-inflammatory mechanism and oxidative stress
is seen in both diseases.[13] The sedentary lifestyle in COPD
may also contribute to the risk of developing cardiovascular
diseases.[14]
In this study, arrhythmia (99-49.5%) was the most common
findings on ECG, RVH in 61 (30.5%) cases, RAE was found
in 52 (26%) patients, right bundle branch block in 20 (10%)
cases, and poor progression of R wave in 24 (12%) cases.
These all have a significant correlation with COPD. Right
axis deviation was found in 30 (15%) cases (P = 0.073,
r = 0.127), which had no significant correlation with COPD.
On ECHO, tricuspid regurgitation (117-58.5%) was the
most common findings and pulmonary hypertension found
in 116 (58%) cases, LVDD in 113 (56.05%) cases, RAE was
found in 79 (39.5%) cases, RVH in 74 (37%) cases, and RV
enlargement in 55 (27.5%) cases.
In this study, in ECG, P pulmonale were found in 26%
(52/200) of patients. P pulmonale in various studies - Scott
found incidence of 32.7% in their studies.[15] Murphy and
Hutcheson found 26.4% incidence of P pulmonale.[16] The
variability of the incidence of the P pulmonale in various
studies may be due to the fact that percentage of severe
COPD patients may vary in their studies. The findings of P
pulmonale in this study is similar to the findings of Murphy
and Hutcheson.[16] P pulmonale have been used as indirect
evidence of RVH by various authors, other regarded it as a
position changes in the heart due to hyperinflation, lowering
of the diaphragm, and vertical position of the heart.[17] In this
study, 30.5% (61/200) of the patients had ECG evidence of
1323        International Journal of Medical Science and Public Health
Assessment of cardiovascular changes among COPD
RVH, with criteria used as given by Braunwald.[18] Murphy
and Hutcheson found 43.66%. Caird and Wilcken found
16% RVH in their studies. Our findings correlate with the
findings of Murphy and Hutcheson.[16] In our study, RBBB
was found in 20 (10%) patients. Warnier et al. found 7%
and Jitendra et al.[19] found in 36% of cases in their studies,
respectively. Hence, our finding is comparable with the
study done by Warnier et al.[20] In the present study, right
atrial dilatation (RAD) was found in 15% of cases, Jitendra
et al. found 26% in their studies, and Krishna and Krishna
in 28% of cases.[19,21] The higher incidence of RAD in above
studies may be that they may have taken more number of
severe COPD patients. Arrhythmias were found in 99 (49.5)
patients, and sinus tachycardia was the most common type
of arrhythmia. Our finding is close to the study done by
Hanrahan et al. (45.3%).[22] In the present study, RAE is
found in 79 (39.5%) patients, Vineeth et al. found 40.9% of
RAE in his study.[23] In our study, RV enlargement was found
in 55 (27.5%) patients while 74 (37%) patients show RVH.
The previous studies done by Suma et al. found that 48% had
features of RV dilatation and 28% had RV hypertrophy.[24]
In the present study, tricuspid regurgitation (TR) was found
in 117 (58.5%) patients on ECHO, and Vineeth et al. also
found TR in 54.5% of patients.[23] In our study, corpulmonale,
which is defined as RV enlargement and/or RVH, is found in
112 (56%) cases, Suma et al. also found 54% in his study.[24]
In our study, PAH was found in 116 (58%) cases which is also
similar (63%) as the study done by Rajiv Gupta et al.[25] In the
present study, LVDD was found in 113 (56.5%) patients. The
previous studies done by Gupta et al. found LVDD on 47.5%
of patients,[26] Vineeth et al. found in 29.5% of cases. The
mechanism behind this in COPD is that chronic RV pressure
overload that leads to bulging of interventricular septum
toward left ventricle and thus impairs LV filling and this in turn
leads to decreased stroke volume and cardiac output. In our
study, systemic hypertension was found in 30% of cases. The
previous studies done by Mannino et al. found 40.1% of cases.[5]
Our study finds less incidence of systemic hypertension, the
probable region may be that it was a rural-based study as there
may be several other risk factors such as sedentary lifestyle,
which is more common in the urban population.
The strength of this study is that with the help of simple non-
invasive ECG cardiovascular abnormalities in COPD patients
can be assessed quickly, which can be further evaluated with
ECHO so that morbidity and mortality due to cardiovascular
diseases in COPD can be reduced by timely intervention.
The strength of this study is that the absence of a control
group limits a definite assessment of the role of COPD in
the pathogenesis of cardiac disorders. The study has a cross-
sectional design, so no causal relationships with clinical
outcomes could be established. The sample size is small,
and therefore, the study with larger sample size with a longer
duration will be required to get the better outcome.
2017 | Vol 6 | Issue 8
Kumar et al.
CONCLUSION
This study shows that cardiac disorders are highly prevalent in
patients with severe-to-very severe COPD. We conclude that
ECG abnormalities are common in patients with COPD. The
prevalence of ECG abnormalities related to cardiac disease
and is higher in those with more severe disease. ECHO is
a simple non-invasive tool for the evaluation of cardiac
functions in patients with COPD during acute exacerbation
as well as during the follow-up of the disease. This would
contribute to the assessment of prognosis in these patients
and assist in identifying individuals likely to suffer increased
mortality and morbidity warranting close monitoring and
intense treatment. Hence, screening of all COPD patients for
cardiac complications should be done routinely.
REFERENCES
1. Global Initiative for Chronic Obstructive Lung Disease  -  Global
Strategy for Diagnosis, Management, and Prevention of
Chronic Obstructive Pulmonary disease. Available from: http://
www.goldcopd.org/uploads/users/files/GOLD_Report_2014_
Jun11pdf. [Last accessed on 2017 Mar 22].
2. Murray CJ, Lopez AD. Alternative projections of mortality and
disability by cause 1990-2020: Global burden of disease study.
Lancet. 1997;349(9064):1498-504.
3. Ochner YN, Rabe KF. Systemic manifestations of COPD.
Chest. 2011;139(1):165-73.
4. GOLD - The Global Initiative for Chronic Obstructive Lung
Disease. Available from: http://www. goldcopd.org/guidelines-
global-strategy-for-diagnosis-management.html. [Last updated
on 2013 Feb 01; Last accessed on 2013 Jun 20].
5. Mannino DM, Thorn D, Swensen A, Holguin F. Prevalence
and outcomes of diabetes, hypertension and cardiovascular
disease in COPD. Eur Respir J. 2008;32(4):962-9.
6. Sin DD, Anthonisen NR, Soriano JB, Agusti AG.
Mortality in COPD: Role of comorbidities. Eur Respir J.
2006;28(6):1245-57.
7. Fabbri LM, Rabe KF. From COPD to chronic systemic
inflammatory syndrome? Lancet. 2007;370(9589):797-9.
8. Hunninghake D. Cardiovascular disease in chronic obstructive
pulmonary disease. Proc Am Thorac Soc. 2005;2(4):44-9.
9. Sorel M, Quesenberry CP, DeLuise C, Lanes S, Eisner MD.
COPD and incident cardiovascular disease hospitalizations
and mortality: Kaiser permanente medical care program.
Chest. 2005;128(4):2068-75.
10. Salcedo EE. The right atrium and the right ventricle. Atlas
of Echocardiography. 2nd ed. Ch. 14. Philadelphia, PA: W. B.
Saunders Company; 1985. p. 281-92.
11. Libby P, Bonow RO, Zipes DP, Mann DL, editors. Braunwald’s
Heart Disease. 8th ed. Philadelphia, PA: Saunders; 2008. p. 251.
12. Dankner R, Goldbourt U, Boyko V, Reicher-Reiss H. Predictors
of cardiac and noncardiac mortality among 14,697 patients
with coronary heart disease. Am J Cardiol. 2003;91(2):121-7.
13. MacNee W. Pulmonary and systemic oxidant/antioxidant
imbalance in chronic obstructive pulmonary disease. Proc Am
Thorac Soc. 2005;2(1):50-60.
2017 | Vol 6 | Issue 8 International Journal of Medical Science and Public Health 
Assessment of cardiovascular changes among COPD
14. Aymerich JG, Lange P, Benet M, Schnohr P, Anto JM. Regular
physical activity modifies smoking-related lung function
decline and reduces risk of chronic obstructive pulmonary
disease: A population-based cohort study. Am J Respir Crit
Care Med. 2007;175(5):458-63.
15. Scott RC. The electrocardiogram in pulmonary emphysema
and chronic corpulmonale. Am Heart J. 1961;61:843.
16. Murphy ML, Hutcheson F. The electrocardiographic diagnosis
of right ventricular hypertrophy in chronic obstructive
pulmonary disease. Chest. 1974;65(6):622-7.
17. Padmavathi S, Veena R. Electrocardiogram in chronic
corpulmonale. Br Heart J. 1972;34(7):658-67.
18. McLaughlin VV, Rich S. Cor-pulmonale. In: Braunwald E,
editor. Heart Disease  - A Text Book of Cardiovascular
Medicine. 6th ed. Ch. 54. Philadelphia, PA: W. B. Saunders
Company; 2001. p. 1936-54.
19. Jitendra J, Apte S, Soni P, Chanchlani R. A study of correlation
between the ecg changes with the duration and severity of
chronic obstructive pulmonary disease. J Evol Med Dent Sci.
2014;3(7):1739-44.
20. Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL,
de Boer A, et al. Electrocardiographic characteristics of
patients with chronic obstructive pulmonary disease. COPD.
2013;10(1):62-71.
21. Krishna NS, Krishna KL. A study of electrocardiographic
changes in chronic obstructive pulmonary disease. Sch J Appl
Med Sci. 2015;3(1G):470-2.
22. Hanrahan JP, Grogan DR, Baumgartner RA, Wilson A,
Cheng H, Zimetbaum PJ, et al. Arrhythmias in patients with
chronic obstructive pulmonary disease (COPD): Occurrence
frequency and the effect of treatment with the inhaled long-
acting beta2-agonists arformoterol and salmeterol. Med
(Baltimore). 2008;87(6):319-28.
23. Vineeth A, Pajanivel R, Surendra MK, Arun P. Prevalence of
cardiac comorbidities and its relation to severity staging of
chronic obstructive pulmonary disease. Int J Curr Res Rev.
2015;7(17):27-33.
24. Suma KR, Srinath S, Praveen. Electrocardiographic and
echocardiographic changes in chronic obstructive pulmonary
disease (COPD) of different grades of severity. J Evol Med
Dent Sci. 2015;4(30):5093-101.
25. Gupta S, Mann S. Correlation between COPD and
echocardiographic features with severity of disease. Natl J
Integr Res Med. 2016;7(1):26-30.
26. Gupta NK, Kumar AR, Srivastav AB, Ved ML.
Echocardiographic evaluation of heart in chronic obstructive
pulmonary disease patient and its co-relation with the severity
of disease. Lung India. 2011;28(2):105-9.
How to cite this article: Kumar A, Gupta AK, Gautam AK,
Kushwaha BK, Yadav P, Verma VK. Assessment of
cardiovascular changes among chronic obstructive pulmonary
disease patients at rural tertiary care center of Northern India. Int
J Med Sci Public Health 2017;6(8):1320-1324.
Source of Support: Nil, Conflict of Interest: None declared.
1324